Advances in Understanding Cognitive Impairment of...
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Advances in Understanding Cognitive
Impairment of Epilepsy
David W. Loring, Ph.D., ABPP (Cn)
Departments of Neurology and Pediatrics
Emory University
Atlanta, GA 30322
American Epilepsy Society | Annual Meeting
December 2, 2011
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Disclosures
NeuroPace
NINDS
UCB
NP and Wada testing
Consultant
Research Support
Research Support
Clinical Income
American Epilepsy Society | Annual Meeting
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Learning Objectives
• Area III: Prevent, limit, and reverse the co-morbidities associated with epilepsy and its treatment.
– Recent advances in understanding cognitive comorbidities in epilepsy
– Methodological challenges studying neuropsychological change over time
– New directions
American Epilepsy Society | Annual Meeting
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Historical Context
• Epilepsy considered degenerative brain
disease before AEDs (mid-19th century)
• Cognitive lifetime effects
(1471 patients) – 9% impaired < 10 convulsions
– 54% impaired 1000+ convulsions
Lennox WG, Lennox MA. (1960). Epilepsy and
Related Disorders. Boston, MA: Little, Brown. William G. Lennox (1884-1960)
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Neuropsychology Impairments
• How often present?
• When do they emerge?
• What are associated factors?
– Underlying biologic substrate and syndrome
– Age of seizure onset or precipitating injury
– AED effects
– Direct seizure discharge effects
• Are cognitive impairments progressive?
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Implications of Epilepsy Diagnosis
• Altered cognitive trajectory
– Slowed cognitive development?
– Loss of cognitive function/cognitive decline?
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“Epilepsy Only” Findings in Pediatrics
Oostrom et al. (2003) Pediatrics, 112(6), 1338-1344.
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New Onset Seizures in Pediatrics
• 282 epilepsy children with normal IQ – 48% idiopathic
– 48% symptomatic/cryptogenic
– 32% generalized
– 65% LRE
Fastenau et al (2009). Neurology, 73, 526-534.
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Results by Syndrome
Fastenau et al (2009). Neurology, 73, 526-534.
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Individual Results
• 27% with single seizure
• Cognitive impairment often precedes
seizure onset
• No group effects for academic
achievement measures
Fastenau et al (2009). Neurology, 73, 526-534.
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Newly Diagnosed Adults
Taylor et al. (2010). Epilepsia, 51(1), 48-56.
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Newly Diagnosed Adults
Taylor et al. (2010). Epilepsia, 51(1), 48-56.
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Cognitive Progression - SANAD
Baker et al. (2011). Epilepsia, 52(6), 1084-1091.
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Cognitive Progression - SANAD
Baker et al. (2011). Epilepsia, 52(6), 1084-1091.
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Cognitive Progression - SANAD
Baker et al. (2011). Epilepsia, 52(6), 1084-1091.
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SANAD Results
• Memory, psychomotor speed, executive
function were domains most likely to
decline
• Seizure freedom not strongly related to
change
• TPM related to change on 4/16 variables
• Measures changing typically different at
baseline
• Practice effect increases separation
Baker et al. (2011). Epilepsia, 52(6), 1084-1091.
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Significant Test-Retest Improvements
4-yr TLE NP Outcome
%
%
%
%
%
%
%
%
%
0
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
Perc
ent C
han
ge
Controls Epilepsy
Hermann et al.(2006). Ann Neurol, 60, 80-87
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Age-related Practice Effects on
Memory
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Z-S
co
re
Chronological Age
Salthouse (2010). Neuropsychology, 24(5), 563-572.
30 40 50 60 70 80
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Practice Effect Trajectories in
Location Learning “Epilepsy Only”
50
52
54
56
58
60
62
64
66
Dx 3 mos 12 mos ~ 42 mos
Patients
Controls
Oostrom et al. (2005). Brain, 128(7), 1546-1555.
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Cognitive Trajectory and Practice
Effects
Functionin
g
Time
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Verbal Learning Age Regression
Helmstaedter and Elgar (2009). Brain, 132(Pt 10), 2822-2830.
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Cross Sectional Design
• Avoids contamination with practice
effects
• Relies on retrospective seizure
characterization
• Difficult to identify individual
trajectories from single timepoint
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Percent Abnormal Decline (Z < -2)
Hermann et all (2006). Ann Neurol, 60, 80-87
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
Controls
Epilepsy
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Social Cognition
• Processing of social information and
cues
• Deficits seen in Asperger syndromes
• Often attributed to frontal lobe function
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Social Cognition
• Theory of Mind- ability to attribute
mental states (e.g., intentions, beliefs,
desires) to others
• Theory of Mind: Faux Pas – Sally has short blonde hair. She was at her Aunt
Carol’s house. The doorbell rang. It was Mary, a
neighbor. Mary said “Hello”, then looked at Sally
and said “Oh, I don’t think I’ve met this little boy.
What’s your name?” Aunt Carol said “Who’d like
a cup of tea?”
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Social Cognition: Faux Pas
• Decreased in epilepsy (FLE > TLE)
• Unrelated to age or number of AEDs
• Related to education, age of onset,
and executive function in NP
• Better ecological measure of
executive/non-verbal function?
• Related to QoL, employment, social
success?
Giovagnoli et al (2011). Epilepsia, 52(11), 1995-2002
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Conclusions
• Cognitive function often predates
seizure onset – Altered cognitive trajectory
• Longitudinal and cross-sectional
designs have different strengths and
limitations
• Cognitive testing predicting complex
social behavior will increasingly be
studied